Adult Education Enrollment form

Personal Identifying Information

DL/ID State*

DL/ID Number*

Age*

in years

Contact Information

Mobile Phone

Work Phone

Home Phone

Email*

Equal Opportunity Information

Veteran Characteristics

Employment and Education Information

Hours Employed per Week*

Highest School Grade Completed*

1-12 or 0 for no grades completed

Please enter a number from 0 to 12.

Post-Secondary Follow-up Questions

for Outside the US only

From what Country was the degree or credential obtained?*

From what Institution was the degree or credential obtained?*

How may years of work experience do you have in this field?*

Migrant and Seasonal Farmworker Characteristics

Public Assistance Information

Additional Youth Characteristics

Additional Reportable Characteristics

Status at Program Entry

Date released from Incarceration

(YYYYMMDD)

One-Stop Program Participation

Participant received services under Title 1, Chapter 4, Subtitle C of WIOA

Adult Education: Yes

WIOA YouthBuild Grant Number

For Corrections and Institutional Program Participants

Special Program Type

Referral Type

Participant Acknowledgement and Release of Information

The information provided is complete and correct to the best of my knowledge. I agree to abide by Adult Education Program policies, rules and regulations. I further understand the submission of false information is grounds for rejection of my application, withdrawal of acceptance, and cancellation of enrollment. My signature below shall constitute acknowledgement to statistical use of my records of enrollment, progress, credential obtainment, and transition to postsecondary enrollment or employment. My signature below also authorizes use of my personally identifiable information, including my employment and wage information pre, during and post- enrollment for audit, study and evaluation of the Adult Education and Literacy program performance and other state and federally- funded programs. Such programs may include but are not limited to those under the laws administered by the Texas Education Agency and the Texas Higher Education Coordinating Board. I acknowledge that the Adult Education and Literacy program and that TWC may release personal identifiable information to other local, state, federal, partners and/or stakeholders for verification of state and federal program requirements, performance reporting, audit, evaluation, study and to monitor the programs performance. Participants who are 17 and 18 years of age must have written parental permission or qualify for another exemption from compulsory attendance law. Additional information may be found at: TWC Website Privacy & Security Information – https://www.twc.texas.gov/agency/laws-rules-policy/website-privacy-security-information

Participant Signature*

Parent/Guardian Signature

For students 18 and under only